FY 2024 Quarterly Cost Share Technical Assistance Request for Payment

District *

PY2021 Master Agreement Number

21 - 035 -

Period Covered by this request (select all that apply) *

1st Quarter {July 1, 2023 - September 30, 2023}

2nd Quarter {October 1, 2023 - December 31, 2023}

3rd Quarter {January 1, 2024 - March 31, 2024}

Submitted By: *

Title *

District Employee

County Finance

Email address *

Phone: *

Budget Catagories:

Salary/Benefits *

The following amounts are not required unless your district requested your allocation to be split among these categories. Your Master Agreement reflects the amounts you were allocated for each.

(This is not common)

Mileage:

Equipment:

Employee Travel Cost:

Other Operating Expenses:

Upload Current Expended County budget for your District for time period you are billing for (this should be an official report from your county finance to show the salary and expenses paid out) *

Comments or Additional Information:

Please email Paula.Day@ncagr.gov or call 919-707-3786 with any questions or concerns.

Signature *

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